With an association established between abnormal hip anatomy and the development of hip osteoarthritis (OA) in the 1960s (1) and 70s (2) and an increasing understanding of the pathophysiology of OA, it has become evident that management should be directed toward recreating normal hip anatomy. This has led to the development of a number of hip-preserving techniques. These include periacetabular (PAO) and proximal femoral osteotomy, surgical hip dislocation, mini-arthrotomy and femoral head–neck debridement and hip arthroscopy. To avoid unnecessary surgery the orthopedic surgeon with an interest in hip-preserving techniques must carefully consider the indications and contraindications with the intention of reducing early treatment failure.

From a review of the literature, treatment failures in hip preservation surgery are not uncommon. One of the main difficulties with assessing success and failure of joint-preserving surgery of the hip is that surgical techniques have changed over time as well as diagnostic criteria with the advent of high resolution multiplanar MRI. This in turn influences patient selection as well as how one defines failure: Is a repeat hip arthroscopy a failure or is it the need for total hip replacement or a decreasing functional score. When looking at dysplasia, for example, in the early days of its treatment, proximal femoral osteotomy (varus or valgus) was the treatment of choice but now the periacetabular osteotomy is the workhorse. With regard to labral tears, initial treatment was solely hip arthroscopy but with improved diagnostic tools femoroacetabular impingement (FAI) has been identified as the main cause of labral tears leading to the introduction of surgical dislocation as a technique to correct FAI. Interestingly within the last 5 to 10 years, hip arthroscopy has had a resurgence with or without a mini-open anterior arthrotomy, and is now the preferred technique to treat FAI with significant advances in labral repair and reconstruction techniques. This rapid and constant evolution of surgical techniques in hip joint–preserving surgery makes it a very difficult field to determine proper patient selection as well as defining success and failure.

In the case of the periacetabular osteotomy which has the longest published follow-up of all the hip-preserving techniques, Table 53.1 illustrates that up to 9% of patients have had a total hip replacement at a mean follow-up of 3.5 years (3). This increases to 11% (4) if failure is considered to be radiographic evidence of osteoarthritis grade III according to Tönnis (5) with a minimum follow-up of 2 years. There are three studies with more than 20-year follow-up (6,7,8) with a failure rate between 32% and 39.5% with one study reporting no failures, although this was a small, highly selected group of patients with a considerable loss to follow-up (8).

There are relatively few reports regarding the mid- to long-term follow-up of isolated proximal femoral osteotomies in the management of posttraumatic and developmental conditions of the hip. Historically, the commonest indication for an intertrochanteric osteotomy (ITO) was for the adult sequelae of hip dysplasia. However, with the relative success of rotational osteotomies of the pelvis, isolated ITOs are indicated only occasionally.

At 10 years, a failure rate between 11% and 19% has been reported in patients undergoing an intertrochanteric varus osteotomy for the treatment of hip dysplasia (9,10). Longer follow-up has been associated with higher failures of between 13% and 40% at 15 to 20 years (9,10) and 50% at 25 years (9).

The results of valgus extension osteotomies performed for primary and secondary osteoarthritis have not been too encouraging with 46% showing radiographic evidence of deterioration of the osteoarthritis with only 15% showing no change in the radiographic grading (11).

A review of patients who have had an arthroscopic debridement of acetabular labral tears revealed a survivorship of 91% at 12- to 16-month follow-up (12,13), 71% to 75% at 2 to 5 years (12,14) and 63% at 10 years (12).

Patients who have undergone a mini-arthrotomy via an anterior approach have had encouraging results with 97.1% survivorship at 2 years (15) and 89% at just under 5 years (16).